Fractures and Dislocations about the Shoulder in the Pediatric Patient

1. Fractures and Dislocationsabout the Shoulder in the Pediatric Patient Steven Frick, MD Created March 2004; Revised August 2006

2. Developmental Anatomy- Ossification Centers and Physes • Scapular ossification centers – acromion, coracoid, glenoid, medial border • Proximal humeral physis – tent shaped, 80% of longitudinal growth • Medial clavicular physis – last to close 23-25 yrs

3. Clavicle Fxs • Most common fx in children • 50% in <10 yo • Usually midshaft • Almost always heals, usually clinically insignificant malunion • Remodels within 1 year • Complications very uncommon

4. Clavicle Fx Patterns • Most in middle • 5% distal • <5% medial • Beware nutrient foramen- not a fx

5. Clavicle Fractures Greenstick common

6. Typical Healing

7. Clavicle Birth Fxs • Large baby • Pseudoparalysis • Simple immobilization • If no BP palsy active movement should return early

8. Congenital Pseudarthrosis of the Clavicle • Right side • Except with dextrocardia • If symptomatic in older child – Excise, tricortical graft, fixation

9. Clavicular Nonunion

10. Distal Clavicle Fx / “AC” Injury • Often intact periosteum • Usually remodels • Nonoperative tx

11. Distal Clavicle Fractures- Classification • Similar to adults • Based on amount and direction of displacement

12. Distal Clavicle Injuries – Periosteal Sleeve

13. Periosteal Sleeve Fills In

14. Type IV AC Dislocation 11 yo female Ped vs car

15. Initial XR

16. from front ------------from behind Distal clavicle posterior Coracoid Acromion

17. Suture Fixation around Coracoid POSTOP PREOP

18. Final X-ray- Full Motion

19. Medial Clavicular Injuries • Medial clavicular physis last to close – 22-24 yo • Clavicle shaft usually anterior • May displace posteriorly • Serendipity view or CT if suspect

20. CT Scan – Posteriorly Displaced Medial Clavicle Injury

21. Scapula Fractures • May be a sign of significant trauma • Usually nonoperative treatment • Growth centers may be confused with fracture • Axillary view often helpful Coracoid base fracture

22. Scapula Fractures - Classification • Can have fracture through common growth center of coracoid and glenoid

23. Scapula Fractures - Classification • Body • Neck • Glenoid • Acromion • Coracoid • Intraarticular or extrarticular

24. Glenohumeral Dislocations • Rare in children < 12 years old • High risk of recurrent instability when initial dislocation occurs in childhood or adolescence • Anterior, Posterior or Inferior direction • Traumatic or Atraumatic etiology

25. Glenoid Dysplasia • May predispose to instability • May be primary or secondary (after brachial plexus palsy)

26. Traumatic Shoulder Dislocation • Gentle reduction • Immobilization for approx 3 weeks • Shoulder rehabilitation • Surgical stabilization /reconstruction reserved for recurrent instability

27. Atraumatic Instability • Often multiple joint ligamentous laxity • Multidirectional instability usually present • May be voluntary (discourage) • Rotator cuff strengthening

28. Proximal Humerus Fxs • Birth injuries • 0-5 yo Salter I • 5-11 yo metaphyseal • 11 to maturity – Salter II • Others rare (III, IV)

29. Birth Fractures of theProximal Humerus • Often Salter I type • Great remodeling potential • Simple immobilization

30. Proximal Humerus – Acceptable Alignment • Great remodeling potential – 80% of humeral length contributed by proximal physis • Shoulder ROM compensatory • Age dependent? – some studies state that even older adolescents have acceptable functional outcomes after nonoperative treatment of prox humerus fxs

31. Neer – Horowitz Classification- Proximal Humeral Physeal Fractures • Grade I- < 5 mm • Grade II - < 1/3 shaft width • Grade III - <= 2/3 shaft width • Grade IV - > 2/3 shaft width

32. Metaphyseal Fxs

33. Remodeling over 6 Months

34. Pinning Proximal Humerus • Usually don’t need to • Most recent studies quote high complication rates (pin migration, infection) • If used leave pins long and bend outside skin, consider threaded tip pins • Even in older adolescents remodeling occurs • Few functional deficits

35. Percutaneous Pinning-this technique may lead to pin migration

36. Pinning BEND PINS TO PREVENT MIGRATION, THREADED TIPS

37. Treatment Principles-Proximal Humerus • Closed treatment for vast majority • If markedly displaced, attempt closed reduction and immobilize • Reserve closed reduction and pinning, open reduction for fractures with significant displacement (> Neer II) in older adolescents, recurrent displacement

38. Early Healing Noted 3 Weeks after Closed Reduction in Adolescent 3 weeks after closed reduc. Injury film

39. Percutaneous Screw Fixation

40. Shoulder Immobilization- Coaptation Splint

41. Complications of Proximal Humerus Fractures • Malunion with loss of shoulder ROM – rarely functionally significant • Shortening – up to 3 -4 cm seemingly well tolerated • Neurologic and vascular compromise less common than in adults

42. Shoulder Region Fractures- Indications for Open Reduction • Open fractures • Displaced intraarticular fractures • Multiple trauma to facilitate rehabilitation • Severe displacement with suspected soft tissue interposition

43. Humeral Shaft Fractures in Children • Neonates – birth trauma • Neonates to age 3 – consider possible non-accidental trauma • Age 3-12 – often pathologic fracture through benign bone tumor or cyst • Older than age 12 – treatment like adults

44. Birth Fractures • Simple immobilization • May have pseudoparalysis • Little attention to realignment or reduction needed

45. Pathologic Humeral Fracture through UBC Note fallen leaf sign and also pseudosubluxation inferiorly

46. Humeral Shaft Fractures- Treatment • Usually closed methods • Sling and swathe • Coaptation splint • Fracture bracing • Hanging arm cast

47. Segmental Humeral Fractures- “Hanging Arm” Cast Treatment Use collar and cuff rather than sling to allow gravity to help align fracture

48. Humeral Shaft Outcomes • Malunion common, but usually little functional loss • Remodels well • Initial fx shortening may be compensated for by later overgrowth • Nonunion uncommon • Radial nerve palsy less common, if occurs usually neuropraxia If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org E-mail OTA about Questions/Comments Return to Pediatrics Index